Calcium Glcuonate in Asystolic Arrest?

[akroeze]

Ok so last night I had another mid-20 y/o VSA (last was on Friday) and the doc did several things that surprised me. First the background:

Pt was well known to the ER staff for being a poorly controlled diabetic (seen her a half dozen times for DKA). We found her in the inevitable dungeon basement with no light. We go through our three no shock protocol (asystole) and transport. Due to extrication from residence we were on scene about 10-15 minutes in total I believe with a 3 minute transport. We got there and as soon as they saw who it was the following happened:

The doc started by intubating (RT hadn't arrived yet) and that isn't unexpected while the nurses tried to get a couple of lines started on her arms. He then went right into starting a central line in the femoral area (don't know much about them). That's the first thing that surprised me, didn't know that was common practice in an arrest. Secondly, he ordered a BGL to be done, Epi, Atropine, Insulin (not sure of dose... I think 10 units but could be wrong), D50, Sodium Bicarb and Calcium Gluconate.

I can sorta see the justification for all of them except the Calcium Gluconate... can someone explain this one to me?

I'm not sure what order those were in and the insulin order was after he found out the glucometer read "HI" I believe.

[AZCEP]

First, keep in mind that a capillary sample for your BGL will probably be inaccurate in a cardiac arrest. The blood stops moving so it can't deliver the sugar to the tissues.

The frequent DKA patient that finally arrests needs a couple of things to bring them back. First would be fluid volume. DKA will cause a level of dehydration unlike most other causes. That might justify early central access, if there were difficulties getting peripheral lines.

The acidosis that is associated will skew the level of K+ to the high side as well. It is not uncommon to treat the hyperkalemia in a code, but remember that once the blood sugar returns to normal your treatment will cause a degree of hypokalemia. Typically the presenting rhythm will be tachycardic, due to the hypovolemia. Without seeing the strip, Epi/Atropine are reasonable PEA drugs. I would have gone with the Bicarb/Calcium before the Insulin, because it will have a more direct effect on the myocardium.

Now for the calcium. Calcium gluconate or chloride will stabilize the transmembrane potential in the myocardium. When there is an excess amount of potassium outside the cell, the sodium and calcium won't want to move out as easily. This creates a situation that does not allow the muscle cells to contract/relax as they are supposed to. Your doc was trying to stabilize a suspected hyperkalemia with the Bicarb/Calcium/Insulin/D50. Although, if the patient is already hyperglycemic, there isn't really a reason to through more sugar into the equation.

What you saw was pretty standard. Was there any change in the patient's status following all of this? Otherwise good practice.

[akroeze]

Well just wanted to point out that it was Asystole, not PEA so the strip was pretty flat

He put in two amps of sodium bicarb in the end IIRC. Also, there were two pressure infused lines running (1 central and 1 20ga peripheral). They worked her for something like 20-25min after we got her there and then called it.

[Ridryder 911]

ditto with Azcep... Hyperkalemia, if you kaexolate he would had prbably gave that too... Not unusial to have brady-aystole arrest with hyperkalemic patients.

Be safe,

R/R 911

[ERDoc]

Was the pt a dialysis pt?

[akroeze]

No, not that I'm aware of.

[als_medic_uk]

Although some doctors still use calcium chloride in the treatment of asystole, it is not supported nor recommended as an effective drug to use when a patient is asystolic. There was [a while ago] a report into the use of calcium chloride [during asystole] and it showed NO effectiveness, they compared it with saline, and the results were both as futile. Most reports have been anecdotal, and have failed to substantiate its effectiveness. Calcium chloride is of no importance in resuscitating obstinate asystole in the pre hospital cardiac arrest setting. So I would just forget you ever heard it :-) if that is possible?

Cases Study - APP - BJM - 1992 pp135-149

I looked up the case, of what I remembered, as an avid Journal reader.

If anyone is interested?! Oh I am rhetorical today.

[buckeyedoc]

Was the pt a dialysis pt?

We have it in our protocols for dialysis pt.'s in arrest. I have yet to push it, though. I haven't read any articles on it usefulness in aystolic arrest.

Doc

[akroeze]

Although some doctors still use calcium chloride in the treatment of asystole, it is not supported nor recommended as an effective drug to use when a patient is asystolic. There was [a while ago] a report into the use of calcium chloride [during asystole] and it showed NO effectiveness, they compared it with saline, and the results were both as futile. Most reports have been anecdotal, and have failed to substantiate its effectiveness. Calcium chloride is of no importance in resuscitating obstinate asystole in the pre hospital cardiac arrest setting. So I would just forget you ever heard it :-) if that is possible?

Cases Study - APP - BJM - 1992 pp135-149

I looked up the case, of what I remembered, as an avid Journal reader.

If anyone is interested?! Oh I am rhetorical today.

This wasn't a simple asystole, it was hyperkalemic induced.

[als_medic_uk]

Akroeze:

“This wasn't a simple asystole, it was hyperkalemic induced.”

I understand that Hyperkalaemia was present, due to acidosis, and yes I can see a reason for using Calcium gluconate if the patient was not asystolic [the Calcium gluconate would not lower the Potassium, but would improve ECG] however the patient was asystolic, and the use for Calcium gluconate as I previously stated is not warranted. Sometimes doctors may over try to resuscitate a patient, and I'm afraid this is what happened, they may have been more successful, if the Calcium Gulonate had been administered prior to asystole. And just to inform you, Sodium bicarbonate is not recommended for treating hyperkalaemia as it fails to lower Potassium serum levels.

Regards